YCH AED Dr. Cheung Chi Kin, Arthur 8th Oct 2014 JCM OSCE (Answer) YCH AED Dr. Cheung Chi Kin, Arthur 8th Oct 2014

Question 1

Question 1 What are the X ray findings? (1.5 marks) Left ankle sprained 2 days ago Presented with ankle pain & limping gait X ray was performed What are the X ray findings? (1.5 marks) Which type of fracture does this girl have? (0.5 mark) What is the specific name for this fracture? (0.5 mark) What are the mechanisms of this injury? (1.5 marks) What is the descriptive name for the fracture also involving metaphysis of distal tibia? (0.5 mark) What is the treatment of choice? (0.5 mark)

Question 1 What are the X ray findings? (1.5 marks) A radiolucent/ fracture line at left distal tibia Extending from epiphysis to epiphyseal plate Soft tissue swelling around ankle Which type of fracture does this girl have? (0.5 mark) Salter-Harris type 3 fracture

Question 1 What is the specific name for this fracture? (0.5 mark) Tillaux fracture What are the mechanisms of this injury? (1.5 marks) In adolescents, the medial part of epiphyseal plate closes first while the anteriolateral part still opens During forced external rotation of foot Epiphyseal plate is weaker than ligament, therefore lateral epiphysis is prone to avulsion fracture

Question 1 What is the descriptive name for the fracture also involving metaphysis of distal tibia? (0.5 mark) Triplane fracture What is the treatment of choice? (0.5 mark) Operative treatment (internal fixation) if joint surface displacement > 2mm

Question 2

Question 2 F/14 Good past health Presented with repeated vomiting x 1/52 Associated with abdominal pain after food Bowel opening normal Thin body build, abdomen soft List four important differential diagnoses in this case. (2 marks)

Question 2 List four important differential diagnoses in this case. (2 marks, any 4 of below) GI: peptic ulcer/ pancreatitis/ small bowel obstruction Gyn: hyperemesis gravidarum/ molar pregnancy/ UTI/ twins Diabetic ketoacidosis Increased intracranial pressure/ post head injury (In this case, Urine wbc nit –ve, PT –ve; Hstix 5.6; CT brain NAD)

Question 2 CT scan of abdomen was performed. Describe the findings and what is the likely diagnosis? (2 marks)

Question 2 CT scan of abdomen was performed. Describe the findings and what is the likely diagnosis? (2 marks) There is a very narrow distance between the abdominal aorta and the SMA, measuring 4.9mm (normally 13-34mm), where the third part of duodenum passes through The diagnosis is Superior Mesenteric Artery Syndrome (due to lack of retroperitoneal or mesenteric fat)

Aorta-SMA angle is 10 degrees (normal 28-65)

Question 2 How do you dispose this patient? (0.5 mark) What is the another structure which can be entrapped between SMA & aorta? (0.5 mark)

Question 2 How do you dispose this patient? (0.5 mark) Admit Surgery What is the another structure which can be entrapped between SMA & aorta? (0.5 mark) Left renal vein (Nutcracker Syndrome) - Presented with haematuria, left-sided varicocele

Question 3

Question 3 M/42 Hx NPC 2007 in remission Presented with fever & sore throat x 1/7 BP 139/69 P112 RR18 Temp 39.0 SpO2 98% No stridor or neck swelling XR neck was performed

Question 3 What are the X ray findings? (1 mark) What is the diagnosis? (0.5 mark) Name 2 common pathogens. (1 mark) What is the initial management in AED? (2.5 mark)

Question 3 What are the X ray findings? (1 mark) Thumbprint sign ballooning/ air-trapping in hypopharynx What is the diagnosis? (0.5 mark) Acute epiglottitis

Question 3 Name 2 common pathogens (1 mark, any 2 of below) Haemophilus influenzae type B (less prevalent since introduction of vaccine in 1987) Grp A beta haemolytic streptococci (most common) Streptococcus pneumoniae Staphylococcus aureus

Question 3 What is the initial management in AED? (2.5 mark, any 5 of below) Manage in Resuscitation room Avoid lie flat and vigorous throat examination Supplemental oxygen via face mask IV access, blood test, culture IV antibiotic (e.g. Augmentin 1.2g or Zinacef 1.5g) Consult ENT & ICU Prepare Difficult Airway Management (DAM)

Only 15-20% adult patients required an artificial airway Only 15-20% adult patients required an artificial airway......majority of patients without respiratory distress can be managed conservatively under close monitoring

Question 4

Question 4 F/55 Good past health, non smoker, non drinker Presented with cough & throat discomfort x2/52 Throat clear, neck soft, no cervical LN Chest clear, no added sound Few high pitched breath sound during expiration Otherwise systemically well, ambulatory ENT consulted, normal laryngoscopy to VC CXR was performed

Question 4 Name 3 differential diagnoses. (1.5 marks) What is the positive finding on CXR? (0.5 mark) Name 3 important negative findings on CXR. (1.5 marks) Name 3 important investigations. (1.5 marks)

Question 4 Name 3 differential diagnoses. (1.5 marks, any 3 of below) Foreign body aspiration Infection e.g. tracheitis – bacterial, TB Trachea tumor/ subglottic stenosis Tracheomalacia External compression to trachea What is the positive finding on CXR? (0.5 mark) A radioopague lesion in lower trachea above carina

Question 4 Name 3 important negative findings on CXR. (1.5 marks) No hyperinflated lung field/ collapse No pneumomediastinum No tracheal deviation Name 3 important investigations. (1.5 marks) Contrast CT thorax Bronchoscopy +/- biopsy Sputum for AFB smear, culture & cytology

Bx confirmed CA trachea

Question 5

Question 5 F/32 Good past health Presented on day 10 post delivery with sudden onset bi-temporal headache and bilateral blurred vision Exam: Right homonymous hemianopia CNs, limb power & sensation normal No cerebellar sign CT brain normal

MRI T2 FLAIR (Fluid attenuated inversion recovery) sequence * By the time when MRI was performed, patient had slightly improved visual field From http://radiopaedia.org/articles/posterior-reversible-encephalopathy-syndrome-1 MRI T2 FLAIR (Fluid attenuated inversion recovery) sequence

Question 5 What are the MRI findings? (1 mark) What is the most likely diagnosis? (0.5 mark) What is the alternative important diagnosis? (0.5 mark) Name 3 predisposing factors for this condition. (1.5 mark) Name one proposed mechanism for this condition. (1 mark) What is the prognosis for this patient? (0.5 mark)

Question 5 What are the MRI findings? (1 mark) Hyperintense lesions on T2 FLAIR sequence over bilateral occipital region What is the most likely diagnosis? (0.5 mark) Posterior reversible encephalopathy syndrome (PRES) What is the alternative important diagnosis? (0.5 mark) Embolic stroke

Question 5 Name 3 predisposing factors for this condition. (1.5 mark, any 3 of below) Hypertensive emergency Eclampsia/ Pre-clampsia Receiving immunosuppressant/ chemotherapy Bone marrow or stem cell transplantation Haemolytic uraemic syndrome Systemic lupus erythematosus

Question 5 Name one proposed mechanism for this condition. (1 mark) Endothelial dysfunction and breakdown of cerebral autoregulation, causing vasogenic edema involving especially the subcortical white matter of parietal and occipital lobe What is the prognosis for this patient? (0.5 mark) Usually benign with complete reversal of clinical symptoms within several days

Thank you Good Luck for Exam 2015!